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Con: Etomidate—The Ideal Induction Agent for a Cardiac Anesthetic?

  • Anita K. Malhotra
    Correspondence
    Address reprint requests to Anita K. Malhotra, MD, Department of Anesthesiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Mail Code H187, 500 University Drive, PO Box 850, Hershey, PA 17033
    Affiliations
    Department of Anesthesiology, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
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Published:November 05, 2012DOI:https://doi.org/10.1053/j.jvca.2012.08.023
      AN IDEAL INDUCTION AGENT would be one that has rapid on- and offset, is easy to administer, and is devoid of clinically significant side effects. Such an agent does not exist currently. Drawbacks to currently available induction agents include the high incidence of hypotension and pain on injection with propofol; dysphoria, tachycardia, hallucinations, and increased secretions with ketamine; hypotension, and an increased incidence of laryngospasm with barbiturates. Etomidate often is the favored induction agent for patients who are hemodynamically compromised because of its relative cardiovascular stability. However, there is ongoing debate about its usage in critically ill patients because of its inhibition of adrenal steroidogenesis.
      • Albert S.G.
      • Ariyan S.
      • Rather A.
      The effect of etomidate on adrenal function in critical illness: A systematic review.
      • Annane D.
      Etomidate and intensive care physicians.
      • Annane D.
      ICU physicians should abandon the use of etomidate!.
      • Cherfan A.J.
      • Tamim H.M.
      • AlJumah A.
      • et al.
      Etomidate and mortality in cirrhotic patients with septic shock.
      • Cooper M.S.
      • Stewart P.M.
      Corticosteroid insufficiency in acutely ill patients.
      • Fragen R.J.
      • Shanks C.A.
      • Molteni A.
      • et al.
      Effects of etomidate on hormonal responses to surgical stress.
      • Jackson Jr, W.L.
      Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock?: A critical appraisal.
      • Marik P.E.
      Etomidate in critically ill patients Is it safe?.

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      References

        • Albert S.G.
        • Ariyan S.
        • Rather A.
        The effect of etomidate on adrenal function in critical illness: A systematic review.
        Intensive Care Med. 2011; 37: 901-910
        • Annane D.
        Etomidate and intensive care physicians.
        Intensive Care Med. 2005; 31: 1454
        • Annane D.
        ICU physicians should abandon the use of etomidate!.
        Intensive Care Med. 2005; 31: 325-326
        • Cherfan A.J.
        • Tamim H.M.
        • AlJumah A.
        • et al.
        Etomidate and mortality in cirrhotic patients with septic shock.
        BMC Clin Pharmacol. 2011; 11: 22-29
        • Cooper M.S.
        • Stewart P.M.
        Corticosteroid insufficiency in acutely ill patients.
        N Engl J Med. 2003; 348: 727-734
        • Fragen R.J.
        • Shanks C.A.
        • Molteni A.
        • et al.
        Effects of etomidate on hormonal responses to surgical stress.
        Anesthesiology. 1984; 61: 652-656
        • Jackson Jr, W.L.
        Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock?: A critical appraisal.
        Chest. 2005; 127: 1031-1038
        • Marik P.E.
        Etomidate in critically ill patients.
        Crit Care Med. 2012; 40: 301-302
        • Forman S.A.
        Clinical and molecular pharmacology of etomidate.
        Anesthesiology. 2011; 114: 695-707
        • Johnson K.B.
        • Egan T.D.
        • Layman J.
        • et al.
        The influence of hemorrhagic shock on etomidate: A pharmacokinetic and pharmacodynamic analysis.
        Anesthesiology. 2004; 101: 657-659
        • de Jong F.H.
        • Mallios C.
        • Jansen C.
        • et al.
        Etomidate suppresses adrenocortical function by inhibition of 11 beta-hydroxylation.
        J Clin Endocrinol Metab. 1984; 59: 1143-1147
        • Wagner R.L.
        • White P.F.
        Etomidate inhibits adrenocortical function in surgical patients.
        Anesthesiology. 1984; 61: 647-651
        • Ray D.C.
        • McKeown D.W.
        Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock.
        Crit Care. 2007; 11: R56
        • Iribarren J.L.
        • Jiménez J.J.
        • Hernández D.
        • et al.
        Relative adrenal insufficiency and hemodynamic status in cardiopulmonary bypass surgery patients.
        J Cardiothorac Surg. 2010; 5: 26-32
        • Mohammad Z.
        • Afessa B.
        • Finkielman J.D.
        The incidence of relative adrenal insufficiency in patients with septic shock after the administration of etomidate.
        Crit Care. 2006; 10: R105
        • Vinclair M.
        • Vroux C.
        • Faure P.
        • et al.
        Duration of adrenal inhibition following a single dose of etomidate in critically ill patients.
        Intensive Care Med. 2008; 34: 714-719
        • Warner K.J.
        • Cuschieri J.
        • Jurkovich G.J.
        • et al.
        Single-dose etomidate for rapid sequence intubation may impact outcome after severe injury.
        J Trauma. 2009; 67: 45-50
        • Hildreth A.N.
        • Mejia V.A.
        • Maxwell R.A.
        • et al.
        Adrenal suppression following a single dose of etomidate for rapid sequence induction: A prospective randomized study.
        J Trauma. 2008; 65: 573-579
        • Sprung C.L.
        • Annane D.
        • Keh D.
        • et al.
        Hydrocortisone therapy for patients with septic shock.
        N Engl J Med. 2008; 358: 111-124
        • Cuthbertson B.H.
        • Sprung C.L.
        • Annane D.
        • et al.
        The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock.
        Intensive Care Med. 2009; 35: 1868-1876
        • Payen J.F.
        • Dupuis C.
        • Trouve-Buisson T.
        • et al.
        Corticosteroid after etomidate in critically ill patients: A randomized controlled trial.
        Crit Care Med. 2012; 40: 29-35
        • Jabre P.
        • Combes X.
        • Lapostolle F.
        • et al.
        Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: A multicentre randomised controlled trial.
        Lancet. 2009; 374: 293-300
        • Cotten J.F.
        • Husain S.S.
        • Forman S.A.
        • et al.
        Methoxycarbonyl-etomidate: A novel rapidly metabolized and ultra-short-acting etomidate analogue that does not produce prolonged adrenocortical suppression.
        Anesthesiology. 2009; 111: 240-249
        • Cotten J.F.
        • Forman S.A.
        • Laha J.K.
        • et al.
        Carboetomidate: A pyrrole analog of etomidate designed not to suppress adrenocortical function.
        Anesthesiology. 2010; 112: 637-644